Practical considerations and emerging approaches for the management of vasomotor and sexual symptoms in breast cancer patients on endocrine therapies.
This narrative review examines pharmacologic management of vasomotor symptoms (VMS) and decreased libido in breast cancer patients receiving endocrine therapy — a population that commonly experiences new or worsened menopausal symptoms. The authors searched PubMed, Cochrane Library, and Web of Science to summarize established agents (SSRIs, SNRIs, gabapentin, clonidine) and highlight emerging therapies: fezolinetant and elinzanetant (neurokinin 3 receptor antagonists for VMS), and flibanserin and bremelanotide (serotonin/dopaminergic modulator and melanocortin receptor agonist, respectively, for low libido). The review notes that existing options provide inadequate symptom relief, representing a meaningful therapeutic gap. Crucially, the authors emphasize that clinical trials supporting these novel agents explicitly excluded breast cancer patients, meaning their safety and efficacy in this population remain unestablished. The paper aims to equip clinicians with practical considerations for weighing these therapies in breast cancer patients while awaiting dedicated research. Key limitations include the review format, reliance on trials conducted in the general population, and the absence of breast cancer-specific clinical data for the highlighted novel agents.
Why this grade: This is a narrative review synthesizing existing literature; it generates no new primary clinical data and does not conduct meta-analytic pooling, so it is graded as a review rather than a direct evidence grade for efficacy claims.
Introduction Vasomotor symptoms (VMS) and decreased libido are common menopausal symptoms. Patients with breast cancer receiving endocrine therapy experience new or worsening menopausal symptoms. Pharmacologic therapy for VMS has been centered on selective serotonin reuptake inhibitors and serotonin norepinephrine reuptake inhibitors, gabapentin, and clonidine. These therapeutic options fall short in obtaining adequate symptom relief, illustrating a therapeutic gap in efficacious treatment modalities. There are no historical systemic treatment options for low libido. Areas covered This review summarizes the current pharmacologic therapy for VMS, focusing on the practical considerations for use of the novel VMS (fezolinetant, elinzanetant) and libido agents (flibanserin, bremelanotide). Literature search was completed with PUBMED, Cochrane Library, and Web of Science. Fezolinetant is a novel neurokinin 3 receptor antagonist that has demonstrated clinical benefit in patients without a history of breast cancer. For libido management, flibanserin and bremelanotide act as serotonin/dopaminergic modulators and melanocortin receptor agonists, respectively. Expert opinion These novel agents are eagerly awaited therapeutic options; however, clinical trials excluded breast cancer patients. This review provides clinicians with relevant considerations to assess when recommending these therapies for patients with breast cancer, while awaiting ongoing research to give additional insights for best tailoring therapy for this patient population.
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